Money Replaces Willpower In Programs Promoting Weight Loss

Peggy Renzi (middle) talks with her teammates Erika Hersey (left) and Erica Webster. The three are part of a team of nurses in the Bowie Health Center emergency room in Bowie, Md., who are working together to lose weight.

Peggy Renzi (middle) talks with her teammates Erika Hersey (left) and Erica Webster. The three are part of a team of nurses in the Bowie Health Center emergency room in Bowie, Md., who are working together to lose weight.

Gabriella Demczuk
/ NPR

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Originally published on February 20, 2013 3:23 pm

Sticking to a diet is a challenge for many people, but starting next year, Americans may have an even bigger, financial incentive to keep their weight in check. The new health care law includes a provision that would allow employers with more than 50 employees to require overweight workers who do not exercise to pay more to cover their insurance costs.

Some employers, inspired in part by the success of shows like The Biggest Loser, are already designing weight-loss programs that use money to succeed where willpower has failed.

For Peggy Renzi and her colleagues at Bowie Health Center in Bowie, Md., the war against weight is waged in the emergency room where they work.

The nurses say most of their patients are either overweight or obese. They sometimes require extra-large stretchers or ambulances, as well as extra nurses to haul all that extra girth, Renzi says.

And this is not just an issue for patients. The nurses grapple with their own weight and say they face their own temptations. Nyuma Harrison points to a long countertop.

"Sometimes on a shift, this whole table is cake and cookies and chips. And when there's nothing on it, we kind of feel like there's something missing in the world. ... It's nice, it's sociable, but the long-term effects are not that great," the nurse says.

So last month, Renzi, Harrison and three other co-workers entered a national weight-loss contest sponsored by HealthyWage. The company sponsors its own contests and also works with employers to set up similar challenges for their workers.

Over three months, the nurses hope to shed at least 10 percent of their weight and win $10,000. After two weeks, "the Divas" — that's their team moniker — had lost 26 pounds.

The team relies heavily on their mobile phones and social networking sites to track progress and keep tabs on each other. Harrison urges the Divas to call for help when facing temptation. She calls these "man down" calls.

"It's like a 911 call. It doesn't matter where we are — in the bed, asleep, at work — all of a sudden the phones are going off. Everyone's like, 'drink some water, have some lemon, take the bottle away from her,' " she says.

Studies show monetary rewards are effective in helping people who want to quit smoking or taking illegal drugs, says economist John Cawley of Cornell University. But food is different. People need to eat, and going back to old eating habits is a lifelong challenge. Cawley's research shows three-quarters of people give up on diets, even if they stand to gain a lot of money.

Employers and health insurance companies are experimenting with ways to structure financial incentives — as well as disincentives — to encourage weight loss.

King County in Washington state, for example, says it saved $6 million between 2007 and 2011, in part by offering incentives to some 2,000 county employees to lose at least 5 percent of their body weight.

Cawley says the overall objective of pushing employees to become healthier makes a lot of financial sense.

"All of us are paying the consequences of these unhealthy behaviors, so it actually does make sense to set up incentive programs to force people making these choices to take into account the costs that they're imposing on society," he says.

But the structure of the incentive matters, he says. Cawley worries that some programs may create perverse incentives to lose weight quickly but not sustainably. And giving money away may not be the best answer: Cawley's work shows that people fight harder to shed weight if they stand to lose money.

Take Chester Demel. Peer pressure and encouragement didn't help him stick to diets. But hate? Hate motivates.

Last year, Demel pledged on a website called StickK to shed a pound every week. And if he failed, he agreed to fork over $5 to a cause he dislikes. The selection of "anti-charities" spans the political spectrum; Demel chose the National Rifle Association. When he thinks about them, "my blood boils. I get really angry," he says.

Instead of thinking of doughnuts, Demel started hearing the theme from Rocky. Fancying himself a lean and hungry Rocky Balboa, he would scramble up five floors to his New York City apartment. He shed 45 pounds in a year.

"The punitive thing works for me," Demel says.

Harrison, the nurse, says neither money nor punishment alone would work for her or her teammates.

"I think the money is a bonus, but we're really not worried about the money," she says, "not because we have a lot of money, but because if we don't win the challenge, we'll still really be in a good place. So there really is nothing to lose — except some pounds."

And anyway, there are other financial incentives that have nothing to do with prizes.

"I do notice that I spend more in the grocery store," she says, "but I always tell myself, it's a lot cheaper than dialysis."

One way or another, the federal health care law aims to make you lose weight. Either you lighten your body, or the law could lighten your wallet. It's one provision of The Affordable Care Act, and it gets to a vital purpose of that massive law: slowing the increase of health care costs. It tries to do that, in part, by allowing employers to reward and penalize certain behaviors, like participating in an exercise and wellness program. Some companies are already experimenting with these kinds of incentives.

NPR's Yuki Noguchi reports.

YUKI NOGUCHI, BYLINE: For Peggy Renzi and her colleagues, the war against weight is waged right here.

PEGGY RENZI: Mr. Wright? Hi, I'm Peggy. I'm going to be your nurse.

NOGUCHI: The Bowie Health Center emergency room in Bowie, Maryland. The nurses who work here say a lot of their patients are overweight or obese. Renzi says some even require extra-large stretchers or ambulances, as well as extra nurses to haul all that extra girth.

RENZI: I have to push you up a ramp to CAT scan that you may not even fit on.

NOGUCHI: It's not just an issue for patients. The nurses worry about their weight and grapple with their own temptations. To illustrate, Nurse Nyuma Harrison points to a long countertop.

NYUMA HARRISON: Sometimes on a shift, this whole table is cake and cookies and chips. And when there's nothing on it, we kind of feel like there's something missing in the world. So then we go to the vending machine, or someone says, hey, I'm going to run to the Panera. And it's nice. It's sociable, but the long-term effects are not that great.

NOGUCHI: Last month, Renzi, Harrison and three other co-workers entered a weight-loss contest. They chose one set up by a company called HealthyWage, which also helps employers set up similar contests for their workers.

In three months, the Divas - that's the nurses' team moniker - hope to shed at least 10 percent of their weight and win $10,000. In two weeks, they've lost 26 pounds.

The team relies heavily on their phones and social networking sites to track their progress and keep tabs on each other. Harrison urges the Divas to call for help when facing temptation. She calls these man-down calls.

HARRISON: It's like a 911 call. It doesn't matter where we are, and we're - in the bed, asleep, at work - all of a sudden, the phones are, like, going off, and everyone's like, drink some water. Have some lemon. Take the bottle away from her.

(LAUGHTER)

HARRISON: I mean, the first man-down call, she was, like, I'm coming to meet you there.

(LAUGHTER)

JOHN CAWLEY: The problem is is that the vast majority of weight loss attempts fail.

NOGUCHI: Economist John Cawley at Cornell University says studies show monetary rewards can help with smoking or illegal drug cessation. But his research shows three-quarters of people give up on diets, even if they stand to gain a lot of money.

This is relevant because many employers and health insurance companies are experimenting with ways to structure financial incentives, as well as disincentives to encourage weight loss.

And, Cawley says, when the new health care law goes into effect next year, it will allow employers to charge overweight people more for coverage if they don't exercise.

CAWLEY: It actually is our business, and all of us are paying the consequences of these unhealthy behaviors. And so it actually does make sense for us to set up incentive programs to force people making these choices to take into account the costs that they're imposing on society.

NOGUCHI: But Cawley says the structure of the incentive matters. His study shows people shed more weight if they stand to lose money.

Take Chester Demel. Positive encouragement didn't help him. But hate? Hate motivates. Last year, Demel found a website called StickK.com, which helps both individuals and employers set up weight loss and other goals. Demel pledged to shed a pound every week, or else he'd have to fork over $5 to a cause he dislikes. People chose lots of things, but Demel chose the National Rifle Association. When he thinks about them...

CHESTER DEMEL: My blood boils. I get really angry.

NOGUCHI: Instead of thinking of donuts, Demel started hearing this...

(SOUNDBITE OF SONG, "GONNA FLY NOW (THEME FROM ROCKY)")

NOGUCHI: Fancying himself Rocky Balboa, Demel would scramble up the five floors to his New York City apartment. He shed 45 pounds over a year.

DEMEL: And I picture myself running up the stairs in Philadelphia.

NOGUCHI: Fists up?

DEMEL: Oh, absolutely. Fists up.

NOGUCHI: Back in Bowie, Nyuma Harrison grocery shops with her Diva teammates.

(SOUNDBITE OF SHOPPING CARTS)

NOGUCHI: I tell her about the economist's observations, that prize money often doesn't work. She's un-phased.

HARRISON: I think the money is a bonus, but we're really not that worried about the money. And not because we have a lot of money, but because if we don't win the challenge, we'll still be in a good place. So there really isn't nothing to lose, except some pounds.

NOGUCHI: And, anyway, Harrison says, there are other financial incentives that have nothing to do with prizes.

HARRISON: I do notice that I spend more in the grocery store, but I always tell myself: It's a lot cheaper than dialysis.